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Credentialing, Revalidation, Medical Billing Services professionals at The Firm Services by Insurance Business 06 Jun 2017 Healthcare claims that breach the million-dollar mark continue to rise, according to Sun Life’s latest catastrophic claims report covering data from 2013-2016. Among other things, the insurance giant found that the number of multi-million-dollar claimants increased 68% from 114 to 192 during that four-year period. While multi-million-dollar cases make up a “small number” of overall claimants, the firm said they are a “greater proportion” of reimbursement dollars. In 2016, multi-million-dollar cases made up 2.2% of claimants but generated 23% of total stop-loss reimbursements. Over the four-year period, total costs for catastrophic claims reached $6.1 billion, with $2.7 billion paid in stop-loss reimbursements. The firm found that cancer dominates the top 10. Based on dollar amount and percentage of total stop-loss claims, “malignant neoplasms” and “leukemia/lymphoma/multiple myeloma (cancers)” took spots one and two on the list, representing more than a quarter (26.7%) of total stop-loss reimbursements from 2013-2016. Of the top-10 conditions, the highest claim was $3.2 million, for malignant neoplasm (cancer). For breast cancer – the most common form of cancer in the US – an average paid claim amounted to $147,100. IV medications tracked in the study pushed up costs – When looking at data on intravenous drugs, the report showed they accounted for 48% of total paid charges on the top five highest-dollar claimants. Of the 562 claimants exceeding $1 million between 2013 and 2016, 45 generated more than $1 million in high-cost intravenous medications. “Health insurance is for the unexpected. Providing full coverage for catastrophic medical events without lifetime limits as designed under the Affordable Care Act is the right thing to do,” said [...]

Bloomberg- by John Lauerman and David Welch- June 1, 2017, 8:17 AM PDT There are two groups Community Health Systems Inc. can’t push too far: the doctors at its hospitals, and the debtholders it owes billions of dollars. Right now, the creditors are winning, and the doctors aren’t happy. In Fort Wayne, Indiana, the rancor about Community’s neglect of a local health system has gotten so bad that a group of doctors tried to get rid of corporate ownership and buy the company out. And 1,500 miles away on the island of Key West, Florida, doctors say patients are being overcharged so that Community, sometimes called CHS, can rake in cash. The two locations are among Community’s most lucrative, and their conflicts are part of the flip side of an industrywide acquisition binge over the last decade. For-profit hospital chains like Community borrowed billions to snap up rivals, facing massive debt reimbursements just as the benefits of the Affordable Care Act, known as Obamacare, began to wane. “I understand that they have billions in debt and may need to take money from this chain to service it,” said William Pond, an anesthesiologist at one of the Fort Wayne hospitals and president of the county health department’s executive board. “But it’s very disappointing to see the course that CHS is taking and the devastating effect they’re having on our community.” Once the biggest U.S. for-profit hospital chain, Community is selling off other, poorly performing facilities to pay off $2 billion of its $15 billion in debt. Yet even as the company skimps on spending and patient satisfaction lags at key facilities like Fort Wayne, its bonds are rising in value -- an indication that debtholders are betting [...]

Confused about Medicare / Medicaid issues? Ask the experts at The Firm Services CBS News- AP / May 26, 2017, 7:44 AM WASHINGTON -- A growing number of Americans age 40 and older think Medicare should cover the costs of long-term care for older adults, according to a poll conducted by the Associated Press-NORC Center for Public Affairs Research. That option is unlikely to gain much traction as President Donald Trump's administration and Republicans in Congress look to cut the federal budget and repeal President Barack Obama's 2010 health care law. Most older Americans mistakenly believe they can rely on Medicare already for such care, the poll shows, while few have done much planning for their own long-term care. Things to know from the AP-NORC poll of older adults: MOST WANT MEDICARE TO PAY More than half of older Americans - 56 percent - think the federal government should devote a great deal or a lot of effort to helping people with the costs of long-term care, and another 30 percent think it should make a moderate effort to do so. According to the poll, 56 percent of Americans age 40 and over think Medicare should have a major role in paying for ongoing living assistance, up from 39 percent who said so in 2013. Majorities of both Democrats and Republicans now think Medicare should bear a large part of the burden. The poll has other signs of growing support for government involvement in providing long-term care. Seventy percent of older Americans say they favor a government-administered long-term care insurance program, up from 53 percent who said so a year ago. Most also favor tax policies to encourage long-term care planning, including tax breaks [...]

Axios- Bob Herman- May 17 The Department of Justice is intervening in a second whistleblower lawsuit that alleges UnitedHealth Group, the largest health insurance and services company in the country, has defrauded the Medicare Advantage insurance program by exaggerating people's medical diagnoses to obtain more federal dollars. Why this matters: These lawsuits have some explosive allegations and threaten a company that dominates a growing and lucrative Medicare industry. In addition, the Center for Public Integrity and a federal watchdog agency have reported numerous instances of insurers manipulating a Medicare patient's "risk score" to get more money. The bottom line: This will be one of the most closely watched federal court cases in health care considering billions of taxpayer dollars are on the line. UnitedHealth is fighting back: "The complaint shows the Department of Justice fundamentally misunderstands or is deliberately ignoring how the Medicare Advantage program works. We reject these claims and will contest them vigorously," spokesman Matt Burns said. The company also said it has pursued administrative action to resolve what it views are unclear policies. Context: Nearly 20 million seniors and disabled people are enrolled in a Medicare Advantage plan, and UnitedHealth covers almost a quarter of them, or about 4.7 million. The back story: The latest whistleblower allegations come from the company's former director of finance who oversaw the Medicare Advantage business — someone with deep knowledge of the "risk adjustment" coding practices in question. Here are some eye-catching claims from the lawsuit: UnitedHealth looked at medical charts to add patient diagnoses where possible, but it did not always delete invalid diagnoses. Top executives, all the way up to UnitedHealth CEO Stephen Hemsley, were aware of an internal program that verified medical claims and [...]

NY Times- By THOMAS KAPLAN and ROBERT PEAR MAY 4, 2017 WASHINGTON — The House on Thursday narrowly approved legislation to repeal and replace major parts of the Affordable Care Act, as Republicans recovered from their earlier failures and moved a step closer to delivering on their promise to reshape American health care without mandated insurance coverage. The vote, 217 to 213, held on President Trump’s 105th day in office, is a significant step on what could be a long legislative road. Twenty Republicans bolted from their leadership to vote no. But the win keeps alive the party’s dream of unwinding President Barack Obama’s signature domestic achievement. The House measure faces profound uncertainty in the Senate, where a handful of Republican senators immediately rejected it, signaling that they would start work on a new version of the bill virtually from scratch. “To the extent that the House solves problems, we might borrow ideas,” said Senator Lamar Alexander of Tennessee, chairman of the Senate health committee. “We can go to conference with the House, or they can pass our bill.” Even before the vote, some Republican senators had expressed deep reservations about one of the most important provisions of the House bill, which would roll back the expansion of Medicaid under the Affordable Care Act. With $8 Billion Deal on Health Bill, House G.O.P. Leader Says ‘We Have Enough Votes’ MAY 3, 2017 But a softening of the House bill, which could help it get through the Senate, would present new problems. For any repeal measure to become law, the House and the Senate would have to agree on the language, a formidable challenge. The House voted on Thursday on a revised health care bill that would [...]

Credentialing? Let the experts at The Firm Services complete it for you. BY LAUREN CLASON, THE HILL EXTRA - 04/13/17 03:00 PM EDT A far-reaching Medicare payment proposal cleared a crucial hurdle this week, as the federal health program seeks to reward doctors for keeping patients healthy. The pitch from the American College of Surgeons would allow more than 75 different specialty doctors to participate in Medicare’s new value-based payment system. Specialty physicians have been largely left out of the system, commonly known as MACRA after the bill that created it. Doctors would be graded and slotted into four different participation tiers — excellent, good, acceptable and unacceptable. Doctors using a less risky, lower-paying track could only reach the level of “good.” To reach “excellent” and earn bonuses through shared savings, doctors would have to be in the top 10 percent of participants. The surgeons’ group on Tuesday squeaked its proposal past the newly created Physician-Focused Payment Model Technical Advisory Committee, which is reviewing and recommending ideas to Health and Human Services Secretary Tom Price. It didn’t come easy. The surgeons pushed the committee to take a risk in greenlighting the model after the panel expressed significant reservations. The panel had raised questions about a lack of specifics with the software to be used in the program. Members eventually voted to recommend implementation, but only on a limited scale. “We’re all in a learning phase,” Medical Director for Quality and Health Policy Frank Opelka, of the surgeons' group. The model is only the second to earn the committee’s approval. “I feel like we’re building the car while we’re driving it.” The Centers for Medicare and Medicaid Services Innovation Center has approved 11 so-called [...]

Bloomberg News -Zachary Tracer- April 18, 2017, 8:27 AM PDT UnitedHealth Group Inc. is doing well doing business with the U.S. government. Just not in Obamacare. The company has added more than a million customers in its federally-funded Medicare and Medicaid businesses since Dec. 31, bringing the total in the company’s public programs and seniors unit to 14.9 million, it said in a statement Tuesday announcing first-quarter results. It had a total medical membership of 49.3 million people, even after largely quitting the Affordable Care Act’s markets that many insurers once regarded as a source of millions of new customers. Shares of the biggest publicly traded U.S. health insurer gained 1 percent to $168.90 at 10:50 a.m. in New York. They’re up 31 percent in the last 12 months through Monday’s close. The company has been expanding in Medicare, where it offers private health plans for the elderly, and in Medicaid, where it helps states manage low-income individuals. Those businesses have proven to be more lucrative than Obamacare’s individual market, where UnitedHealth broadly retreated after offering plans on the health law’s exchanges in 34 states last year. The trends in UnitedHealth’s government business will help boost profits. The Minnetonka, Minnesota-based company predicted that earnings for the full year, excluding some items, will be $9.65 to $9.85 a share. That’s well above the $9.51 projected by analysts, according to an average of estimates compiled by Bloomberg, and above the company’s January forecast. First-quarter earnings excluding some items were $2.37 a share, topping the $2.17 average of analysts’ estimates. Distracted Rivals UnitedHealth has also benefited from the entanglement of its major rivals in two massive deals. Humana Inc. and Aetna Inc., the No. 2 and No. 3 sellers [...]

Confused about Medicare / Medicaid issues? Ask the experts at The Firm Services Published: Thursday, April 13, 2017 11:19 p.m. CDT • Updated: Thursday, April 13, 2017 11:19 p.m. CDT By Trudy Lieberman, Rural Health News Service What’s going to happen to Medicare? That’s not an insignificant question given the political shift in Washington. Now, with Republicans controlling the presidency and both houses of Congress, some ideas they’ve been pushing for years have a chance of passing. Those ideas would drastically change the way Medicare works for those already on it and those joining in the next few years. Medicare is wildly popular, but that popularity doesn’t necessarily translate into understanding of a very complex program, what’s happened to it, and what may happen. Writing about Medicare for nearly 30 years and watching it evolve, I’ve seen how easily Congress has already made big changes with hardly a peep from the press or the public. The same could happen again. In this column, I discuss a few of those possible changes gleaned from my decades of experience covering the program. Since the election, there’s been talk of “voucherizing” or privatizing Medicare, an idea Republicans have been pushing for 20 years. Under a fully privatized arrangement, Medicare would no longer be social insurance like Social Security but more like Obamacare with everyone eventually buying their coverage from private insurance companies. Beneficiaries would receive a sum of money, likely to be called “premium support” instead of the more dire-sounding “voucher,” to help buy their coverage. The amount of support and how well it would keep pace with medical inflation would be buried in the details Congress would hash out. Today, the government provides the benefits [...]

The Accenture study also finds that half of these victims were subject to medical identity theft and on average had to pay $2,500 in out-of-pocket costs per incident. Healthcare IT News - By Bill Siwicki February 20, 201708:23 AM Twenty-six percent of U.S. consumers have had their personal medical information stolen from healthcare information systems, according to results of a new study from Accenture released today at HIMSS17 in Orlando. The findings show that 50 percent of those who experienced a breach were victims of medical identity theft and had to pay approximately $2,500 in out-of-pocket costs per incident, on average. In addition, the survey of 2,000 U.S. consumers found that the breaches were most likely to occur in hospitals (the location cited by 36 percent of respondents who experienced a breach), followed by urgent-care clinics (22 percent), pharmacies (22 percent), physicians’ offices (21 percent) and health insurers (21 percent). 50 percent of consumers who experienced a breach found out about it themselves, through noting an error on their credit card statement or benefits explanation, whereas only 33 percent were alerted to the breach by the organization where it occurred, and only 15 percent were alerted by a government agency, according to the survey. Among those who experienced a breach, 50 percent were victims of medical identity theft, the survey found. Most often, the stolen identity was used to purchase items (cited by 37 percent of data-breached respondents) or used for fraudulent activities, such as billing for care (37 percent) or filling prescriptions (26 percent). Nearly one-third of consumers had their social security number (31 percent), contact information (31 percent) or medical data (31 percent) compromised, according to the survey. Unlike credit card identity theft, where [...]

Bloomberg- by Zachary Tracer , David McLaughlin , and Andrew M Harris February 8, 2017, 4:05 PM PST February 9, 2017, 2:37 PM PST After 18 months of courtship and court cases, two massive deals that would have reshaped the U.S. health insurance industry have both been declared dead, blocked by judges who said they’d do unacceptable harm to competition in the industry. Now, the companies are right back where they started. Anthem Inc.’s $48 billion deal to buy Cigna Corp. was blocked by a federal judge late Wednesday, weeks after another judge halted Aetna Inc.’s bid for Humana Inc. Anthem filed a notice of appeal on Thursday, and Aetna and Humana have said they’re still deciding whether to appeal. The question now becomes what the companies will do with the large piles of cash they allocated for the acquisitions, and whether they’ll try anew at fresh takeovers under a Trump administration, whose antitrust officials could be more amenable to large consolidations. They could also opt for something more conservative in the face of widespread uncertainty about the future of the U.S. health system. But first, they may be back in court. “Anthem is significantly disappointed by the decision,” Chief Executive Officer Joseph Swedish said in a statement. “If not overturned, the consequences of the decision are far-reaching and will hurt American consumers.” Cigna, for its part, said it “intends to carefully review the opinion and evaluate its options in accordance with the merger agreement.” CEO David Cordani has estimated that his company will have $7 billion to $14 billion of deployable capital, with the high end including extra debt the company could take on if it decided to make acquisitions. “We have a track record [...]